Huron Ophthalmology - Minor Policy Form

Huron Ophthalmology, PC

Permission to Treat a Minor without a Parent/Guardian Present

Huron Ophthalmology must receive permission from a child’s parent or legal guardian before providing an eye exam or any treatment from injury or illness that if non-life threatening. This form gives us legal permission to examine and treat your child in case you cannot accompany him/her to the clinic for their visit. If the party accompanying your child (baby-sitter, friend, relative, etc.) does not present this information, the clinic will attempt to contact you to request permission to examine and treat your child.

Note:

• Minors may not receive an exam or treatment without a parent/legal guardian, unless the parent/legal guardian gives their consent for another adult party, must be 18 years of age, to accompany the minor patient for their appointment.

• The adult party accompanying the minor will be responsible for making any medical decisions when/if there is an emergency during the minor’s appointment.

• A new “Permission to Treat a Minor without a Parent/Guardian Present” form is required for each visit that a minor will be seen without his/her parent/legal guardian

• Every three years a parent/legal guardian must accompany the minor patient for their appointment, in order for Huron Ophthalmology to ensure appropriate insurance/billing information, signature of HIPAA forms, etc.

I grant _______________________________ (an adult into whose care, the minor has been entrusted), to arrange for and authorize routine eye exam and/or treatment at Huron Ophthalmology on ______________(date).

______ Please initial here if you are authorizing the minor to seek and consent to an exam and treatment without parent/legal guardian present. We/I acknowledge that we are responsible for all reasonable charges in connection with the exam, care, and treatment rendered.

Please send the insurance card and co-pay (if applicable) to the appointment.